Abstract
As public health aims to improve health outcomes of all populations, social justice is argued to be the philosophy on which public health is based. A social justice approach to population health requires the field to recognize that the inequities in society have negative consequences for health. The purpose of this work is to develop a framework for integrating social justice into a public health curriculum. We used an interprofessional approach to create a definition of social justice, and develop a training program and evaluation plan. The program weaves social justice throughout the core MPH curriculum. The social justice definition is the foundation of the curriculum which is composed of eight key social justice domains with competencies directly aligned with each of the domains. Our evaluation plan focuses on students’ change in understanding of social justice in public health. The overarching goal is to explicitly integrate social justice into an MPH curriculum such that students can work toward health equity and justice in their careers.
Throughout public health literature on the subject of social justice, the word “inextricably” is often used to define the inherent tie between the two. As public health aims to improve the health outcomes of all populations, social justice is argued to be the philosophy on which public health is based—its core value. Despite this centrality, many argue it is overlooked or taken for granted in the field (Galea, 2016). Social justice and public health are inherently tied through definitions of health, human rights, and the centering of social determinants. Driven by student interest as well as the need to keep curriculum relevant, colleges and universities are increasingly developing social justice programs to address pressing issues in contemporary society (Lois, 2020). For example, Dominican University, launched a stand-alone social justice major in 2019, Ohio Wesleyan University offers a social justice major with one course specifically focused on activism, Harvard University implemented a “social justice certificate” program for its students, UW-Madison hires social justice interns to help with justice effort around campus, and Georgetown students can supplement their education with social justice activism work (Airaksinen, 2018; Cai, 2019; Ciccio, 2018; Mcdonald, 2019; Sabes, 2018, 2019). These examples illustrate the response of higher education to student interest and the values of social justice.
Georges C. Benjamin, MD, Executive Director of the American Public Health Association (2002–present), wrote in 2015, “Perhaps more than most fields of work, public health is paved with good intentions, with the worthy goals of alleviating suffering and extending life. But we are at a point in public health history in which good intentions and good science are no longer enough. We must listen more to the people we serve, have uncomfortable conversations, and increase our push for social justice both locally and globally (Benjamin, 2015).”
A social justice approach to population health requires the field to recognize that the inequities in society due to race, gender, sexuality, ethnicity, and economic inequity, among others, have negative consequences for health (Braveman et al., 2011). We need to confront these issues head on.
Program and Local Climate
The St. Catherine University (St. Kate’s) Masters in Public Health (MPH) Global Health program, located in St. Paul, Minnesota, was launched in 2016 to be aligned with the vision and mission of the institution, emphasizing global health, diversity, and social justice. With a global health focus, the program works to prepare public health professionals on playing an integral role in the interconnected world. Throughout this paper, we use the term public health to encompass both local and global health. The students are working toward reducing health care disparities, strengthening health systems and improving public health locally and globally. Throughout the program, they are learning how to use global health perspectives and policy to foster collaboration, program management and strategic analysis skills. However, students enroll into the program with diverse experiences and educational backgrounds and many are unfamiliar with social justice concepts. We found that students were not making the same connections between public health and social justice. Though we launched the program with the goal of providing a justice-oriented curriculum, through student course evaluations and advisee conversations, we learned that we need to be more explicit about teaching social justice and include social justice narratives more often.
Our public health faculty and staff have also noted the need for resources to help facilitate challenging topics. We have grappled with the questions of “who is left out, which students benefit from not confronting hard topics in class, etc.” Gaps in our curriculum resulted in disparate student outcomes. This feedback fueled the response to reforming our curriculum to enhance our instruction around social justice and equity. Social justice is not just achieved through a specific means of instruction but rather through a curriculum reform (Council on Education for Public Health (CEPH), 2021).
We can also not ignore the voices of our community at large. Racial and ethnic disparities in social determinants of health have long existed in the United States and as seen through the COVID-19 pandemic which is having a disproportionate impact on racial and ethnic minorities (Tai et al., 2021; Weinstein et al., 2017). After the murder of George Floyd, the Minnesota House of Representative and certain counties have declared racism as a public health crisis shifting the way racism is seen in public health (Cook, 2020; Marinan, 2020). The COVID 19 pandemic and the murder of George Floyd highlight the social and structural systems that were established to maintain power and white privilege are deeply woven into the fabric of this country (Altman, 2020; Spievack & Okeke, 2020). In order to make the changes necessary to address the issues above, students of public health must be educated with social justice and health equity at the center of their teachings. This is not simply more individualized cultural competency but approaches that face the structural inequities and power dynamics that must be challenged (Bailey et al., 2017). Therefore, as a new and growing public health program, the graduate curriculum at St. Kate’s offers the opportunity to be a space in which students develop these skills.
Additionally, as an MPH in global health, we also have to reckon with the injustice in global governance systems that have perpetuated poverty in low income countries (Ali & Murphy, 2020). Students need to be prepared to confront injustice and inequity while promoting participation and equity in their work with underprivileged, marginalized, indigenous, and/or oppressed populations of the global south. As such, it is critical to have a historical, cultural, political, and economic understanding on factors that impact global health, including financial and trade policies.
To address this glaring need, we proposed an MPH curriculum reform with a more intentional explicit focus on social justice. The overarching goal is to provide students with the skills necessary to not only discuss issues of injustice, but work toward health equity and justice in their careers. In addition, we have established goals for our students, faculties, and community members. The overarching goals for the MPH curriculum, students, faculty, and community members are listed in Table 1.
Goals of the St. Kate’s MPH Curriculum Reform.
Groundwork
We utilized an interprofessional approach to identify gaps, create reform, and implement changes to the curriculum. We spent the 2019 to 2020 academic year meeting with students, individual faculty, the public health advisory board, and convened a group of stakeholders to brainstorm ideas, gather student and community needs, and research best practices.
We started our groundwork with a comprehensive review of the existing core curriculum. We had individual meetings with each faculty who taught one of the eight MPH core courses, six faculty in total. In each meeting we reviewed the courses’ syllabi, the reading materials, the in-class examples, and class topics and identified where social justice could be more explicit. We also gathered feedback from students who had taken each course for input on social justice topics that were missing from the syllabus. The following excerpts from student feedback collected during that time illustrate their desire for curriculum modification: Systemic racism continues to allow for white students to decide if students of color’s voices should be included in the classroom. . ..This system doesn’t work. The work to change it requires continuous effort. It must be a priority. It must be visible (MPH Student, class of 2022). More than ever I need an MPH from a place that is committed to talking about racism and equity (MPH student, class of 2020).
As a result of that groundwork, we identified the following as essential activities to enhance social justice in MPH curriculum:
Develop a definition of social justice specific to the public health context. This definition is considered an emergent definition and is a point of focus for the MPH program.
Build a complimentary social justice “training program” to be integrated into the nine core MPH courses. This training program consists of one in-class session for each core course that serves as the point in the course to highlight these social justice ideas and/or skills. The training program will have its own social justice domains and associated competencies.
Evaluate this training program by implementing a mixed method, non-experimental longitudinal evaluation. We evaluate two stakeholder groups, MPH students and MPH faculty who teach the core courses impacted.
We introduced the curriculum proposal to our St. Kate’s Public Health Advisory Board (PHAB) in the Fall of 2019. PHAB is a diverse group of public health stakeholders that includes representatives from local public health government and non-governmental organizations, hospitals and clinics, current MPH students, and alumni. The members gave input on topics that should be included in a social justice training program, skills they would like people in the public health workforce to have, gaps in their workforce, and our definition of social justice. We also convened an advisory board specifically for input into this curriculum reform. This advisory board consisted of six faculty and four staff from various disciplines across the University with experience and expertise working in social justice, two current MPH students, and one MPH alumnae. We met three times in the 2020 to 2021 academic year. In the first meeting we reviewed and finalized the social justice definition and discussed the overall training program. In the second meeting we finalized the social justice domains, developed course topics, and drafted competencies. In our final meeting, we mapped topics to domains and competencies and gathered input on our evaluation plan. We met again with PHAB in the Spring of 2021 to review the final program.
Resulting Curriculum
As a result of our interprofessional work, we developed a definition of social justice, a training program with social justice domains and associated competencies, nine lesson plans, orientation materials, and a comprehensive evaluation plan.
Social Justice Definition
The definition of social justice in Public Health at the St. Kate’s MPH program is:
Social justice in public health is demonstrated in both
Beliefs:
Health care is a human right.
Everyone is treated with dignity and respect.
Everyone deserves equitable access to the resources and knowledge needed in order to live a life of health and well-being.
Everyone has a personal responsibility to work toward personal and institutional development.
Actions:
Verbalizing and speaking out against social injustice.
Challenging the root causes of inequity through advocacy and in practice.
Ensuring that voices of the communities who are most impacted are a part of the process.
Actively participating in collaboration with communities as a process to activate change.
Strengthening community capacity to define priorities and work toward change.
Challenging the social structures that uphold systemic inequality through monitoring, accountability, and research practices.
Ensuring delivery of equitable and quality healthcare.
Participating in decision making practices that utilize a rights-based approach to governance.
Promoting funding policies that advance economic development.
Health outcomes are determined by society’s distribution of wealth and privilege, with special attention to socioeconomic status, race, gender, sexuality, ability, ethnicity, and other determining factors. Thus, public health education and practice must challenge inequity and dismantle its root causes in the pursuit of actualizing health and well-being for all.
Social Justice Training Program
The training program consists of social justice domains and competencies, described below. All students are oriented to the program through orientation materials to serve as a foundation and framework for their public health studies. Students were also introduced to the social justice definition, and are provided an overview of the nine class topics, domains, and associated competencies.
Social Justice Domains
The social justice training program is composed of eight key areas, or domains, that make up the toolbox needed to work toward social justice. The focus of these areas are based upon our definition of social justice in public health. Students will leave with the understanding that working toward social justice is multi-layered. It requires commitment and action demonstrated through: (1) root cause analysis, (2) analysis and assessment, (3) planning, monitoring, and evaluation, (4) partnership and Engagement, (5) advocacy, (6) access to quality healthcare, (7) community development, and (8) economic development & funding policies. See Figure 1.
Social justice domains.
Each domain is associated with specific competencies that are delivered through the class sessions. Table 2 lists the domains and associated competencies.
Competencies for Social Justice Training Program.
Class Session Outline
After establishing the domains and competencies, we mapped the domains to a topic corresponding to each course. There are nine core courses in the MPH program. Each course is three credits and meets for 3 hours. We dedicated one 3 hour class session in each of the core courses to this training program. The topics were chosen as they aligned with the content of the core courses and were a way to explicitly weave the social justice domains and competencies into the existing curriculum. Table 3 lists the different class topics and their corresponding domains. Each of the nine class sessions starts with a land acknowledgment and instruction includes a root cause analysis, small and large group discussions, readings, videos and lectures, and our evaluation. Each domain is covered at least once over the nine class sessions with some occurring more than once. We cover domain root cause analysis in all class sessions as understanding our history is crucial for improving the practice of public health professionals (Scally & Womack, 2004). Some domains are covered more than once as class topics lend themselves to overlapping domains. Class content is delivered by course instructors and guest lecturers who have expertise on the topic. The goal is not to force any particular perspective on students but rather to encourage discussions and critical thinking on the topic. The class sessions have a self-reflective component. Students spend part of the class period doing reflective writing in response to prompts related to the class topic. This serves two purposes, to allow space for reflection and serve as a journal to see individual development over time. Figure 2 showcases the timeline of when students would take certain sessions.
Mapping out Domains to Class Topics.
Timeline of courses.
Measurable Outcomes for Evaluation
The evaluation focuses on comparisons between pre- and post-tests for each of them. We collect a combination of qualitative and quantitative data to analyze within each group. The quantitative data includes measures of social justice concepts before and after the program as well as students’ ability to articulate social justice in public health. Qualitative data will offer more nuanced understandings of the experiences of the stakeholders’ groups and the meaning and interpretation of the program’s work. The goal of the evaluation is to offer a complex understanding of what both measurable goals and emergent lessons can be taken from the implementation of this program. In gathering this richer set of data, it will be able to best inform the ongoing development of the program itself.
The evaluation tools measure the following outcome objectives:
- Increased student knowledge of social justice ideas in public health
- Increased student skills and ability to apply social justice to the fieldwork of public health
- Increased critical thinking and capacity for challenging discussions
Students
A pre-test is administered at student orientation prior to their first Fall semester. The pre-test measures a baseline understanding of social justice, ability to identify social justice ideas in public health, and ability to articulate concepts. A post-test assessment is administered at the end of the program to measure changes in understanding of social justice concepts. Baseline measures are given an average score in the three objectives and compared with average scores in the post-test surveys. This provides an objective measure of students’ understanding of social justice in public health. These questionnaires collect demographic information and include Likert-scales as well as close- and open-ended questions for both qualitative and quantitative data collection.
Faculty
All full-time and adjunct faculty are given an online survey before the implementation of the program to gage their confidence in incorporating social justice more explicitly in their courses. The evaluation assists in the development of faculty support and resources and identifies gaps in course curriculum and facilitation. Faculty teaching the core courses where the social justice program is implemented completes a post-course evaluation to gain feedback into how the social justice program affected their students and their course. A summary of the pre and post data collection measures can be found in Table 4.
Summary of Data Collection.
Discussion
Social justice work is long-term work that requires, among other things, in-depth and ongoing research and analysis. More than ever, as inequity continues and more marginalized communities suffer greater harm from myriad diseases, research is needed to base a social justice oriented curriculum in solid and evidence-based ideas and skill development.
The social justice training program within the MPH program at St. Kate’s advances student understanding of social justice concepts and skills as they relate to various areas of public health. The program combines the ideas through readings and discussions along with teaching tangible skills that facilitate students’ ability to incorporate social justice and health equity into public health work. Through the core courses, the program requires students to read selected materials in each core course as it relates to the subject matter and engage in critical thinking and discussion on the ideas or information presented. Additionally, each core course offers skills training so that students gain experience in integrating social justice into their work.
The majority of schools of public health in the United States and the requirements for students who graduate from them have little explicit focus on social justice as a core value. Georges C. Benjamin, MD, Executive Director of the American Public Health Association (2002–present), wrote in 2015, “It is simply impossible to talk about the roles that racism and discrimination play in the health of our communities without taking a hard look inward—without asking ourselves and our colleagues to think about the ways that our institutions and organizations perpetuate bias and historical trauma (Benjamin, 2015).”
High quality training programs can prepare MPH graduates to promote health equity from a social justice framework. As such, social justice and health equity frameworks should be further integrated and centered in the field of public health. Upon graduating from an MPH program, we believe students should be able to:
Articulate how social justice and public health are related
Have tangible skills to work toward health equity in public health careers
Understand the root causes of inequity
Challenge the social structures that uphold systemic inequality
This work serves as a framework for public health educators at a time when social justice is a necessary part of an MPH education. The WHO Commission on the social determinants of health did not just deem social justice and health equity central to public health, it also determined it to be possible, stating, “Achieving health equity within a generation is achievable, it is the right thing to do, and now is the right time to do it” (World Health Organization (WHO), 2008). Training the next generation of health care professionals matters if structural oppression is to be overcome (Bailey et al., 2017). With an explicit focus on social justice, MPH graduates will be at the forefront of this shift in public health and social justice.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was partially funded by St. Catherine University’s Academic Excellence GHR grant.
